Dopamine Nation

CHAPTER 2
Running from Pain
met David in 2018. He was physically unremarkable: white, medium
build, brown hair. He had an uncertainty about him that made him seem
younger than the thirty-five years documented in the medical record. I found
myself thinking, He won’t last. He’ll come back to clinic once or twice and
I’ll never see him again.
But I’ve learned my powers of prognostication are unreliable. I’ve had
patients I was convinced I could help who proved to be intractable, and
others I deemed hopeless who were surprisingly resilient. Hence, when
seeing new patients now, I try to quiet that doubting voice and remember that
everyone’s got a shot at recovery.
“Tell me what brings you in,” I said.
David’s problems began in college, but more precisely the day he walked
into student mental health services. He was a twenty-year-old sophomore
undergraduate in upstate New York looking for help with anxiety and poor
school performance.
His anxiety was triggered by interacting with strangers, or anyone he didn’t
know well. His face would flush, his chest and back would get damp, and his
thoughts would get jumbled. He avoided classes where he had to speak in
front of others. He dropped out of a required speech and communications
seminar twice, eventually fulfilling the requirement by taking an equivalent
class at community college.
“What were you afraid of?” I asked.

---

“I was afraid to fail. I was afraid to be exposed as not knowing. I was
afraid to ask for help.”
After a forty-five-minute appointment and a pencil-and-paper test that took
less than five minutes to complete, he was diagnosed with attention deficit
disorder (ADD) and generalized anxiety disorder (GAD). The psychologist
who administered the test recommended he follow up with a psychiatrist to
prescribe an antianxiety medication and, David said, a “stimulant for my
ADD.” He was not offered psychotherapy or other nonmedication behavioral
modification.
David went to see a psychiatrist, who prescribed Paxil, a selective
serotonin reuptake inhibitor to treat depression and anxiety, and Adderall, a
stimulant to treat ADD.
“So how did it go for you—the meds, I mean?”
“The Paxil helped with the anxiety a little at first. It dampened down some
of the worst sweating, but it wasn’t a cure. I ended up changing my major
from computer engineering to computer science, thinking that would help. It
required less interaction.
“But because I wasn’t able to speak up and say I didn’t know, I failed an
exam. Then I failed the next one. Then I dropped out for a semester not to
take a hit on my grade point average. Eventually, I switched out of the school
of engineering altogether, which was really sad because it was what I loved
and really wanted to do. I became a history major: The classes were smaller,
only twenty people, and I could get away with being less interactive. I could
take the blue book home and work by myself.”
“What about the Adderall?” I asked.
“I’d take ten milligrams first thing every morning before class. It helped me
get that deep focus. But looking back, I think I just had bad study habits.
Adderall helped me make up for that, but it also helped me procrastinate. If
there was a test and I hadn’t studied, I’d take Adderall around the clock, all
through the day and night, to cram for the exam. Then it got to where I
couldn’t study without it. Then I started needing more.”
I wondered how hard it had been for him to acquire additional pills. “Was
it hard to get more?”

---

“Not really,” he said. “I always knew when a refill was due. I’d call the
psychiatrist a few days before. Not a lot of days before, just one or two, so
they wouldn’t get suspicious. Actually, I’d run out like . . . ten days before,
but if I called a few days before, they’d refill it right then. I also learned it
was better to talk to the P.A., the physician’s assistant. They’d be more likely
to refill without asking too many questions. Sometimes I’d make up excuses,
like say there was a problem with the mail-order pharmacy. But most of the
time I didn’t have to.”
“It sounds like the pills weren’t really helping.”
David paused. “In the end, it came down to comfort. It was easier to take a
pill than feel the pain.”
—
In 2016, I gave a presentation on drug and alcohol problems to faculty and
staff at the Stanford student mental health clinic. It had been some months
since I’d been to that part of campus. I arrived early and, while I waited in
the front lobby to meet my contact, my attention was drawn to a wall of
brochures for the taking.
There were four brochures in all, each with some variation of the word